Death by Data- How Healthcare Providers Went from Historians to Librarians

Thirty years ago, in what might be referred to as BPC (before the personal computer), I took a class asking whether technology made our lives better or worse.  The topic seemed absurd, but it fulfilled a graduation requirement.  The professor from Bell Labs was part techie, part philosopher.  By the end of the semester I didn’t throw away my Walkman, but I also thought the question had merit.  Then I went off to med school and, for the most part, was able to forget about technology- everything was on paper. 

In medical school I learned to review the medical records (huge binders often marked by roman numerals designating volumes related to a patient) and to take a history.  Listen and the patient will tell you the answer was the mantra.  The patient’s problem was a narrative, a story of what happened to them in the past, and how it might have contributed to the present.  The treatment plan was the hoped for future.  Ideally, this all fit into a story that made sense.

Towards the end of my residency, electronic medical records(EMRs) began to appear.  This made sense.  Huge paper binders were difficult to review for a patient and essentially impossible for clinical studies.  However, EMRs were not built to tell a story but rather enter data.  The earliest EMRs were more for collections (revenue cycle) rather than care.  The narrative, the patient’s story was almost an afterthought.

Most of us are familiar with the clinical result.  Providers often has their eyes on the screen rather than on the patient.  Even if the right questions are asked, the information gathered fills tiny boxes, more like books in a library, rather than constructing a story.

Recently Melissa McCormack, a medical researcher at Software Advice, blogged (http://thehealthcareblog.com/blog/2014/01/06/actually-wed-all-be-better-off-with-our-health-records-on-facebook/) asking why medical records couldn’t be more like Facebook, an information timeline (note, she was not suggesting FB become a medical record, but rather EMRs borrow from the structure of FB).  I agree.  Current tools gather data with no real consideration of purpose, of constructing the patient’s narrative.  Stories can be told.  FB has shown it’s possible.  The medical community just needs to think different.

In Greek Mythology curiosity gets the better of Pandora. She opens a box she’s warned not to.  In doing so, bad things fly out- war, disease, envy, etc…She quickly closes it, but it’s too late.  When she opens it again, only thing left in the box is hope.  The question raised by my professor decades ago is truly academic. There is no going back.   We can’t live with technology.  However, technology needs a governor, a brake that ties it back to the problems it is designed to solve.  Data for data’s sake may not make our lives better.  Without constantly considering people and process, we run the risk of making things worse rather than better.  Nothing against librarians, but I would prefer to go back to being a historian.

Healthcare Technology Should Be about Enabling, Not Replacing, People- why it's less about the app and more about the process.

My friend Lisa Suennen recently wrote a thoughtful review of the Computer Electronic Show (#CES) http://www.venturevalkyrie.com/2014/01/11/people-who-need-people-a-ces-follow-up-report/5961.  For those of you unfamiliar with the event, there were more than 2 million square feet of exhibits and roughly 150,000 people last week in Las Vegas.  Digital Health is part of a broader offering covering all things tech.  Amongst all these glittering objects, the of envy for any true geek, Lisa had several interesting observations.  First, that many health entrepreneurs are (as she notes, wrongly) looking for ways technology can replace people, rather than enable people.  There is a general sense that scale (a magic word for the investment community) requires fewer bodies.  Second in her opinion, the ultimate goal should be a mash up, a convergence of IT, devices and services for true value.  I couldn’t agree more.

My efforts focus on collaboration.  Within health IT is what seems obsession with data, EMR’s and dashboards, but for me the future is about teams- getting the right people at the right time to come together.  Without this opportunity for timely expertise and collaboration, the value of data decays.  Information has trouble converting to knowledge.  However, collaboration is messy.  It requires thoughtful consider of how people and process interact with technology.

Replacing the Pager with a PDA.

For decades the pager has been the official form for medical communication.  It is safe and secure.  It is also limited, inflexible and a poor choice for collaboration.  In response, many physicians have adopted texting as an alternative method of communication.  However, as of September 2013, new federal mandates limit texting.  There is a potential 50,000 penalty for texting a single instance of patient information being exposed in an standard text.  The response by many vendors has been ….I have an app for that, to wrap messages in a secure technology.  However, an effective solution needs to be far more nuanced.

In the consumer space, apps can go viral.  However, the social fabric and supporting infrastructure for healthcare presents a number of obstacles.  There is an assumption that all providers will have a PDA.  However, PDAs at work are expressly forbidden by many nursing regulations.  This means messaging must be cross platform.  What if an individual doesn’t want their PDA to be leverage for work responsibilities; is the hospital required to provide a device?  Many hospitals do not have have the necessary wireless/cellular infrastructure to support PDAs.  Most hospitals do not have accurate information on their providers beyond pager numbers and an office address; snail mail remains the de facto form of communication.  

For their part, physicians often do not want to be reach directly.  In part this is a workflow issue.  Imagine a physician is in surgery and receives a call telling a patient needs their attention immediately.  Do they leave the surgery, or stop the surgery and call someone to cover?  There are reasons for call centers.  Practically, there needs to be permissions set by time of day, availability and role for the collaborative communication to be appropriately routed.  This requires high level enrollment into a “service” identifying roles and managing preferences.

The result has been islands of communication.  Groups have adopted apps for internal communication but no real holistic community of providers for collaboration. With the help of a vendor (disclosure- I have invested in the company, #Emerge.MD), St. Joseph’s has deployed a technology enabled service helping people to collaborate.  This service enables provider collaboration by name (eg...Dr. Jones) or by role (neurosurgeon on call).  It incorporates nursing requirements (for desktop messaging) as well as physician preferences.  Via this service teams of people can be brought together text, voice or video.  Importantly, there is sponsorship from a business owner, the hospital and more broadly the Accountable Care Organization.  The executives have something to gain- more cost effective care (throughput issues, access to specialists, etc…). This solution is now spreading through Dignity Healthcare. However, this was not plug and play.  It required extensive knowledge about the people and process rather than strictly technology.   

Even replacing an archaic device, the pager, with a PDA is not about technology but rather about understanding and management of a constellation of social processes. At the end of the day, health and healthcare are personal.  There are many processes that can be automated and improved upon via technology.  But for my money, I am with Lisa.  Transformation will be more about enabling rather than replacing people.   And people require services, not technology.